Week #7: 57-Year-Old Male with High Blood
Pressure (Hypertension (HTN)) | Complete H&P,
SOAP Notes, Diagnosis & Management (100%
Score Guide)
PATIENT INFORMATION
Age: 57 years
Sex: Male
Height: 5’9” (175 cm)
Weight: 195 lb (88.6 kg)
BMI: ~28.8 (Overweight)
Chief Complaint: “My blood pressure has been high.”
Setting: Outpatient clinic (ECG, labs, X-ray available)
History Feedback
, Below you will see the strategy for selecting the "required" questions in this patient
encounter using the OLD-CARTS mnemonic for the HPI.
Reason for Encounter
Start with open-ended patient-centric questions.
Asked X Not asked
Information
Graded Approach Question Response Obtained
Clinic Notes
I was recently at a health fair
in my community where I had
my blood pressure checked.
How can I
The nurse told me that I
● CC Sx help you
should see a doctor because
today?
my pressure is too high. My
wife was concerned and
made the appointment.
Have you
● Assoc Sx gained Yeah, a bit.
weight?
Do you
have any
other...
, Information
Graded Approach Question Response Obtained
Clinic Notes
I was recently at a health
fair in my community
where I had my blood
How can I pressure checked. The
● CC Sx help you nurse told me that I should
today? see a doctor because my
pressure is too high. My
wife was concerned and
made the appointment.
Have you
● Assoc Sx gained Yeah, a bit.
weight?
I suppose so. I'm having
headaches in the morning
that are making me tired
Do you have
all day. Oh, and my wife
any other
says I am not sleeping
symptoms or
● Assoc Sx well... I am not really sure
concerns we
what she means, but she
should
says I wake up a lot. I admit
discuss?
I do feel more tired than I
did 10 years ago—isn't that
just due to aging?
OLD-CARTS for the HPI
Asked
X Not asked
Pressure (Hypertension (HTN)) | Complete H&P,
SOAP Notes, Diagnosis & Management (100%
Score Guide)
PATIENT INFORMATION
Age: 57 years
Sex: Male
Height: 5’9” (175 cm)
Weight: 195 lb (88.6 kg)
BMI: ~28.8 (Overweight)
Chief Complaint: “My blood pressure has been high.”
Setting: Outpatient clinic (ECG, labs, X-ray available)
History Feedback
, Below you will see the strategy for selecting the "required" questions in this patient
encounter using the OLD-CARTS mnemonic for the HPI.
Reason for Encounter
Start with open-ended patient-centric questions.
Asked X Not asked
Information
Graded Approach Question Response Obtained
Clinic Notes
I was recently at a health fair
in my community where I had
my blood pressure checked.
How can I
The nurse told me that I
● CC Sx help you
should see a doctor because
today?
my pressure is too high. My
wife was concerned and
made the appointment.
Have you
● Assoc Sx gained Yeah, a bit.
weight?
Do you
have any
other...
, Information
Graded Approach Question Response Obtained
Clinic Notes
I was recently at a health
fair in my community
where I had my blood
How can I pressure checked. The
● CC Sx help you nurse told me that I should
today? see a doctor because my
pressure is too high. My
wife was concerned and
made the appointment.
Have you
● Assoc Sx gained Yeah, a bit.
weight?
I suppose so. I'm having
headaches in the morning
that are making me tired
Do you have
all day. Oh, and my wife
any other
says I am not sleeping
symptoms or
● Assoc Sx well... I am not really sure
concerns we
what she means, but she
should
says I wake up a lot. I admit
discuss?
I do feel more tired than I
did 10 years ago—isn't that
just due to aging?
OLD-CARTS for the HPI
Asked
X Not asked
